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Z 06FICE USE- <br /> ----------------i---------------- ---------- ---------- <br /> ----------- -----------------------n4 e. <br /> ....... --------- APPLICATION FOR SANITATION PERMIT Permit No. <br /> ---------------------------_----------------------------- {Caimplete in Duplicate} Z_ <br /> ------------------------------- ...... This Permit Expires 1 Year From Date Issued <br /> Date Issued .......... <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION--------- <br /> ..... <br /> ..... . <br /> -- ------------------------------------------------------- <br /> Owner's Name----C., <br /> ----- ----- - ------ -- ........ --- Phone.................................-- <br /> Address--•--------- <br /> 1 ontrac#ors <br /> .Address------------Contractors Name. - ----------------------- ---------------_--- Phone.................................. <br /> ------------------_ <br /> --------------------------------------- ------- <br /> Installation will serve: Residence! Q!, Apartment House [I Commercial [I Trailer Court E] Motel [] Other <br /> Number of living units: ____4_.. Number of bedrooms Number of baths A---- Lot size --- ...... <br /> Water Supply: Public system E] Community system E] Private Depth to Water Table -4.6 ft. <br /> Character of soil to a depth of 3 feet: Sand [-] Gravel [] Sandy Loam [j Clay Loam [] Clay C] Adobe Ej Hardpan C) <br /> Previous Application Made: (If yes,dote--------------------) No � New Construction: Yes E] No Cg, FHA/VA-. Yes [3 No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool p4rmitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well--- ...Distance from foundation.J. ......mate Ial <br /> Te ------------------------------- <br /> No. of compartments-------7.-_-_4---------- L <br /> -Size__�� .... .Liquid depth__ -------------Capacity -L} ... <br /> Disposal Field: Distance from nearest well '.V------Distance from founclatio <br /> Ed ::::::Dislrc,5 to nearest I lin ...... <br /> Number of lines...................------------- Length of each line-------- Width of french T <br /> -------------------- <br /> -filter �'afe ial---(7.. 7 <br /> Type of filter material-12-0--VK....Depth of M r --- - --------Total length______.-------------------------------- <br /> Seepage Pit: Distance to nearest well________________'____Distance from f6uhdation--------------------Distance to nearest lot line..._.______ <br /> �Imber of Liiiin'­g material---------- ------------Size: Diameter-----------_-----------Depth---------------- <br /> Cesspool: Distance from nearest well.................Distance from foundation_____________.__ .Lining material...-_____--.._______.......____`':" <br /> Size: Diameter <br /> El -------------------------------------Depth----------------------------------------------------Liquid Capacity..... .................gels..e <br /> Privy: Distance from nearest well.___ ---------- <br /> -----------------------------------Distance from nearest,build�ing---------- <br /> ------------------I....... <br /> Distance-t� n6lrest lot line----------------------- <br /> r----------------- `a,.......................... -----------------------_--------------------------- <br /> Remodeling and/or repairing (describe)------ ---- ---------- <br /> ................................ <br /> --------------­-----------­---------------------------------------------------------------------...... <br /> -----------------------------------------------------------------------­-------------- <br /> -------------- -----------------------------------------------------------------------------------------------------------------------...........I-----------------------------------------------------------------:_ <br />- --------------------------------------I--------------------------------------------------------------------------------------------•---•-•-----------------== 1, <br /> -------­------------------- --------------- ------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sen Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)- <br /> --------- ------------------------•-----------------._..""..'_40wner and/or Contractor) <br /> Br--•..................................................... --------------------------------------------------------------------------(Title)...................... ------------------- -------------- <br /> JPlot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed an reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------- <br /> ---A---Q ---- -------- -------------------------------- DATE-11-c-------- <br /> REVIEWEDBY------------------------------------- ---------------- ----------------------------------------------------------------------- DATE-i................. <br /> BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE <br /> Alterations and/or recommendations:------------------ -------------------------------------------------------------------------------- <br /> ................ ---------------------------------------------------------­-------------------------------- ------------------------------------------------------------------------------------------------_----------- <br /> --------------------------------------------------------------I------------------------------------- -------------------------------- --­­-------------------------- ----------------------- ----------------------------- <br /> ---------------------------------------------------------1-1-_---------------------­------------------------------------------ --------------------------­-- ........................ <br /> ----• -------•---------------------- ----- ----------------------- ----------------------------------------------------------------------------- ---------------------------------------------------- <br /> FINAL INSPECTION BY------ --------•------•--------- -- <br /> ---------------------- Date---....... ------------- ------ -------- ------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore street 205 West 9th Street <br /> Stockton,California F Lodi,California Manteca,California Tracy,California <br /> CS 9 REVISED B-a9 21% 5-911 ATLAS <br />